Might Insurance Cover a Breast Reduction in the Presence of Degenerative Disc Disease?

Breast reduction is a common covered benefit under many insurance policies. However, this varies between insurance companies. The first thing that you need to find out from your carrier is if it is a covered benefit. You can contact them directly. If you would like to come in for a consultation, my insurance coordination staff could do that for you as well. The next thing to know is how much of your breast tissue will need to be reduced. This is based on your breast size, height and weight. See the link below for more information.

The criteria for an insurance company to provide coverage for breast reduction vary from company to company and plan to plan.  Generally, women who are DDD and larger have enough breast tissue to potentially qualify.  First check the exclusions page of your policy - if breast reduction is listed, it is close to  impossible to obtain coverage (with very few exceptions).  If it is not an exclusion (or if you are willing to fight - usually unsuccessfully), you should see a board-certified plastic surgeon (who is on your plan) for evaluation.  They would be most familiar with the specific additional requirements of your local insurance carrier and plan.

Good luck.

Thank you for the question.

Based on your description you may be an excellent candidate for breast reduction surgery.
 The best way to obtain insurance coverage for breast reduction surgery involves some “hoops” to jump through. The more documentation you have (for example, from your primary care doctor, spine doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure.
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Make sure you're  working with a well-trained/experienced board-certified plastic surgeon.
 
 

Best wishes.

Insurance can frequently cover breast reduction for symptomatic macro mastic. Documentation of tieback problems are frequently necessary

The only way to determine health insurance coverage is having a boarded pS send a predetermination letter to the insurance companies reviewing panel. A witten response is needed to proceed. 

Insurance coverage for breast reduction will vary depending on individual plans, many of which have very restrictive criteria for breast reduction no matter how worthy or what symptoms are involved. The process starts with an insurance predetermination letter to your insurance to learn just what your coverage will allow.
Best of luck,
peterejohnsonmd

Having private health insurance is similar to going to a catered function. Unless you purchased your own policy, just like attending such a (chicken-or-fish) function, you do not have a voice over the menu (or list of covered benefits); it has been ordered and paid for you.

If YOUR particular policy has Breast Reduction "benefits", it means either you or your employer paid for such care and therefore, subject to the insurer's requirements, the operation will be covered. On the other hand, if such care was not pre-paid for, there is no way the insurer will pay for such care REGARDLESS of how beneficial such an operation may be for you.  The concept is similar to all insurance policies; It you had coverage when a storm hits, you will be paid for your damages but if you went bare, the insurer will not pay you a cent.

The best way to go about it is either consult your insurance book or your human resource office. They should be able to tell you. If you are covered, find out WHO the Plastic surgeons working with your insurer are and look them up on our society's website - wwwplasticsurgeryorg. See 1-3 of them and they will advise you.

Peter A Aldea, MD

Hi Mindwhirl,

In your case, it's probably an automatic "Yes."

Actually, each insurance company is different and has its own requirements as to what would constitute a covered procedure (you then have to find a plastic surgeon you're comfortable with who either participates in your insurance or would accept it, if you have out-of-network benefits).  Your first step should be to contact your insurance company to see which plastic surgeons participate in it.  You can then go around to see some of them and, as long as you find one you're comfortable with, you can proceed with that surgeon.  If not, and if your policy has out-of-network benefits, you can call offices of surgeons you would work with and see if they'll accept your insurance.

Either way, once you have a surgeon you can ask that surgeon to help get you through the steps required of your insurance company.  Again, each company is different, and if you want them to pay then you have to go through whatever is required to complete that process.  That often means your surgeon has to send a letter, photos, etc. to the company.

But based on your physical situation (degenerative disc disease) combined with your larger bra size AND the fact that your breasts are dense, I think you're very likely to get approval.

I hope that this helps, and good luck,

Dr. E

With your documented cervical disc disease and the size of your breasts, I think that a breast reduction would probably improve your symptoms but i do not think that your breast hypertrophy is the soe cause of your symptoms. You should probably discuss the potential benefits of breast reduction surgery with your family doctor who can then refer you to a plastic surgeon if he/she feels that you would benefit.

Insurance Coverage for Breast Reduction
 

80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.

1)  Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.

2)  Very big reductions (like from an F cup to a C cup) will usually be covered.

3)  Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.

4)  Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.

5)  DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.

6)  Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.

7)  Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.

8)  Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.

9)  Don't give up. If the first request is denied, demand an appeal.

10)  If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.